A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching?
Wear an N95 mask when in the client's room.
Wear a gown when caring for the client.
Wear a simple face mask when caring for the client.
Place the client in a negative air pressure room.
None
None
The Correct Answer is C
Choice A reason: This is a requirement for Airborne Precautions (used for smaller particles like those in Tuberculosis, Measles, or Varicella). Pertussis droplets are too large to remain suspended in the air, so a standard surgical mask is sufficient.
Choice B reason: Wearing a gown when caring for the client is not necessary, as pertussis is not transmitted by contact with body fluids or surfaces.
Choice C reason: Pertussis (Whooping Cough) is a highly contagious respiratory infection caused by the bacterium Bordetella pertussis. It is transmitted through large respiratory droplets expelled when an infected person coughs or sneezes. Because these droplets are heavy and typically travel only 3 to 6 feet before falling to the ground, Droplet Precautions are required.
Choice D reason: Placing the client in a negative air pressure room is not indicated, as pertussis is not classified as an airborne infection that requires isolation in a specially ventilated room.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: This is incorrect because Sims position is used for clients who have lower back pain, abdominal surgery, or enemas. It is not appropriate for clients who have a closed head injury.
Choice B: This is incorrect because modified Trendelenburg position is used for clients who have hypovolemic shock or poor venous return. It is not appropriate for clients who have a closed head injury.
Choice C: This is correct because semi-Fowler's position is used for clients who have increased intracranial pressure, respiratory distress, or head trauma. It elevates the head and chest to reduce cerebral edema and facilitate breathing.
Choice D: This is incorrect because prone position is used for clients who have acute respiratory distress syndrome, spinal cord injury, or pressure ulcers. It is not appropriate for clients who have a closed head injury.
Correct Answer is D
Explanation
Choice A reason: PaO2 85 mmHg is within the normal range of 80 to 100 mmHg and does not indicate any hypoxemia or oxygen deficiency.
Choice B reason: pH 7.47 is within the normal range of 7.35 to 7.45 and does not indicate any acid-base imbalance.
Choice C reason: HCO3 25 mEq/L is within the normal range of 22 to 26 mEq/L and does not indicate any metabolic disturbance.
Choice D reason: PaCO2 55 mmHg is above the normal range of 35 to 45 mmHg and indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pneumonia, which can impair gas exchange and ventilation.
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